APPLICATION FOR CERTIFICATION OF DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM

DIRECTIONS: After reading the Department's Administrative Rules and the Drug-Free Workplace Program Guide, please complete the following checklist and return only this checklist and a $25.00 check for the certification fee to the address below. Keep the documentation of your compliance in your files for review upon request by your insurer or the Department of Industrial Relations, Workers' Compensation Division.

This is our company's first year of application for certification as a drug-free workplace.

****************************************************************************** TO BE COMPLETED BY THE DEPARTMENT OF INDUSTRIAL RELATIONS, WORKERS' COMPENSATION DIVISION. Date of First Certification:_________________________ Approved By:__________________________________ ******************************************************************************

A statement of actions employer may take against employee or job applicant on the basis of a positive confirmed test result. (Code of Alabama, 1975, §25-5-334 (a)(1)b.) A statement of consequences of an employee's or job applicant's refusal to submit to a drug test. (Code of Alabama, 1975, §25-5-334 (a)(4)) A statement advising employee or job applicant of the existence of the article outlining a certified drug-free workplace program. (Code of Alabama, 1975, §25-5-334 (a)(2)) A general confidentiality statement. (Code of Alabama, 1975, §25-5-334 (a)(3)) EITHER a statement advising employee of Employee Assistance Program (EAP), if employer offers one. OR

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A statement advising employee of employer's resource file of assistance programs and other persons, entities, or organizations designed to assist employees with personal or behavior problems. (Code of Alabama, 1975, §25-5-334 (a)(5)) A statement advising employee or job applicant who receives a positive confirmed test result that he or she may contest or explain the result to the employer within five (5) working days after written notification of the test result. (Code of Alabama, 1975, §25-5-334 (a)(6))

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A statement informing an employee or job applicant of the federal Drug-Free Workplace Act, if it applies to you. If not, write NA. (Code of Alabama, 1975, §25-5-334 (a)(7)) EITHER sixty (60) days notice was given prior to implementation of testing. OR sixty (60) days notice was not required because implementation of program occurred prior to July 1, 1996. (Code of Alabama, 1975, §25-5-334 (b)) Effective date of your Drug-Free Workplace/Substance Abuse Policy. Notice of substance abuse testing is included on vacancy announcements for positions in which testing is required. (Code of Alabama, 1975, §25-5-334 (c)) Notice of substance abuse testing is posted in an appropriate and conspicuous location on employer's premises. (Code of Alabama, 1975, §25-5-334 (c)) Copies of policy are available to employees and job applicants in employer's personnel office or other suitable location. (Code of Alabama, 1975, §25-5-334 (c))

the standards and procedures outlined in the guidelines for certification. C Employer Responsibilities Required for Certification: (Code of Alabama, 1975, §25-5-335 (c)(6) through (12)) The employer is complying with the procedures that are outlined in the guidelines for certification. Laboratory Responsibilities Required for Certification: (Code of Alabama, 1975, §25-5-335 (d)(1) through (3)) The laboratory that the employer is using is complying with the procedures that are outlined in the guidelines for certification.

Employee Assistance Required for Certification:
(Code of Alabama, 1975, §25-5-336) EITHER you have an employee assistance program (EAP) OR you maintain and post other means of employee assistance

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Employee Education Required for Certification:
(Code of Alabama, 1975, §25-5-337 (a)) Hour One of the Employee Education program has been conducted for employees. (Date of Program _______________) Hour Two of the Employee Education program has been conducted for employees. (Date of Program _______________)

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Supervisor Training Required for Certification:

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(Code of Alabama, 1975, §25-5-337 (b)) _____ AND _____ Once a year, two hours of supervisor training on how to recognize signs of substance abuse, how to document and collaborate signs of employee substance abuse, and how to refer substance abusing employees to the proper treatment providers. NOTE: Second half of supervisor training program may be completed within six months after certification. Participation of supervisors with the employees in the above education program.

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Confidentiality Required for Certification:
(Code of Alabama, 1975, §25-5-339) All information received through substance abuse testing is confidential, but may be used or received in evidence, or obtained in discovery, or disclosed in any civil or administrative proceeding when the information is relevant to the employer's defense, e.g., a workers' compensation hearing.

NOTE: Employers should ensure that they have read and understand the Disclaimers of a drug-free workplace program and the information on Maintenance and Revocation of certification. 7. Notarization of Certified Drug-Free Workplace Program ______________________________ Officer/Owner Signature* ______________________________ Title of Officer/Owner

______________________________ Employer Name ______________________________ Date * Application must be signed by an officer or owner.

Sworn to and subscribed before me this __________ day of _____________20____. ____________________________________ Notary Public My Commission Expires________________